Passerotti Carlo C, Barnewolt Carol, Xuewu Jiang, Passerotti Ana Maria A M S, Ward Valerie, Dunning Patricia, Retik Alan B, Nguyen Hiep T
Department of Urology (Robotic Research and Training Center), Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts 02115, USA.
J Urol. 2008 Oct;180(4 Suppl):1790-4; discussion 1794. doi: 10.1016/j.juro.2008.03.085. Epub 2008 Aug 21.
Bladder outlet obstruction can have devastating consequences. Given the poor outcome, intervention in utero has been advocated in an attempt to salvage pulmonary and renal function. We evaluated whether laparoscopic decompression of the obstructed bladder could be performed efficiently by adapting current robot assisted laparoscopic techniques to access the fetus in utero.
At 95 days of gestation 20 fetal sheep underwent ligation of the urethra and urachus. Two to 5 days later robot assisted laparoscopic vesicostomy was performed. Ultrasound of the kidneys and bladder was performed before each procedure. At 135 days of gestation the urinary tract was evaluated to assess the adequacy of bladder decompression and a patent vesicostomy.
After 48 hours of undergoing ligation all fetuses had bilateral moderate hydronephrosis and a markedly distended bladder. In the first 10 fetuses vesicostomy could not be completed laparoscopically due to limited visualization. Additional modifications in trocar placement and gas infusion allowed vesicostomy to be completed laparoscopically in the last 8 fetuses in 2.5 to 4 hours. Urinary tract decompression and a patent vesicostomy were observed in all of these fetuses postoperatively.
We developed specific modifications in current robot assisted laparoscopic techniques and instrumentation to allow the treatment of bladder outlet obstruction in utero. This procedure may be performed efficiently and it may provide advantages over conventional surgery for fetal intervention.
膀胱出口梗阻可产生严重后果。鉴于预后不佳，有人主张在子宫内进行干预，以挽救肺和肾功能。我们评估了通过调整当前机器人辅助腹腔镜技术以进入子宫内的胎儿，是否能够有效地进行梗阻膀胱的腹腔镜减压。
在妊娠95天时，对20只胎羊进行尿道和脐尿管结扎。2至5天后进行机器人辅助腹腔镜膀胱造瘘术。每次手术前均对肾脏和膀胱进行超声检查。在妊娠135天时，对尿路进行评估，以评估膀胱减压是否充分以及膀胱造瘘口是否通畅。
结扎后48小时，所有胎儿均出现双侧中度肾积水和膀胱明显扩张。在前10只胎儿中，由于视野有限，无法通过腹腔镜完成膀胱造瘘术。通过对套管针放置和气体注入进行额外改进，使后8只胎儿能够在2.5至4小时内通过腹腔镜完成膀胱造瘘术。所有这些胎儿术后均观察到尿路减压且膀胱造瘘口通畅。
我们对当前机器人辅助腹腔镜技术和器械进行了特定改进，以实现子宫内膀胱出口梗阻的治疗。该手术可有效进行，且与传统胎儿干预手术相比可能具有优势。
